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Management of the Trigeminocardiac Reflex: Facts and Own Experience Review Article Management of the trigeminocardiac reflex: Facts and own experience Belachew Arasho1,4, Nora Sandu2, Toma Spiriev1, Hemanshu Prabhakar3, Bernhard Schaller1 1Departments of Neurosurgery, University of Paris, France, 2University of Lausanne, Switzerland, 3Neuroanesthesiology, Neurosciences Center, All India Institute of Medical Sciences, New Delhi, India, 4Department of Neurology, Addis Ababa University, Ethiopia Abstract The trigeminocardiac reflex (TCR) is defined as the sudden onset of parasympathetic dysrhythmia, sympathetic hypotension, apnea, or gastric hyper-motility during stimulation of any of the sensory branches of the trigeminal nerve. The proposed mechanism for the development of TCR is—the sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc. It has been demonstrated that the TCR may occur with mechanical stimulation of all the branches of the trigeminal nerve anywhere along its course (central or peripheral). The reaction subsides with cessation of the stimulus. But, some patients may develop severe bradycardia, asystole, and arterial hypotension which require intervention. The risk factors already known to increase the incidence of TCR include: Hypercapnia; hypoxemia; light general anesthesia; age (more pronounced in children); the nature of the provoking stimulus (stimulus strength Address for correspondence: and duration); and drugs: Potent narcotic agents (sufentanil and alfentanil); beta- Dr. Bernhard Schaller, blockers; and calcium channel blockers. Because of the lack of full understanding Department of Neurosurgery, of the TCR physiology, the current treatment options for patients with TCR include: University of Paris, France. (i) risk factor identification and modification; (ii) prophylactic measures; and (iii) E-mail: [email protected] administration of vagolytic agents or sympathomimetics. Key words: Atropine, cardiac reflex, oculocardiac reflex, skull base surgery, DOI: 10.4103/0028-3886.55577 treatment, trigemino Introduction reflex occurs with stimulation of the intracranial portion of the trigeminal nerve.[1] Again Schaller was the first who The trigeminal nerve is the largest of the cranial nerves, subsummarized all these reflexes under the term TCR.[2,9] and it provides sensory supply to the face, scalp, and Since then, there has been much discussion about the reflex mucosa of the nose and mouth.[1-3] Stimulation of the itself and the prophylaxis and treatment of the TCR when trigeminal receptors that innervate the nose and nasal it occurs during intracranial or extracranial procedures. passages is thought to provide an important stimulus for But until now, there exists no clear recommendations the initiation of the trigeminorespiratory reflex and cardiac how to treat the TCR. So, the aim of the present work is to arrhythmias which could arise with it. This has been update knowledge about currently available treatment studied in animals and known for more than a century,[4-6] options for patients with TCR. and is now considered as the trigeminocardiac reflex th (TCR). In the early 20 century, this TCR has gained much Definition and Pathophysiology of the clinical attention, in the form of the oculocardiac reflex (OCR) which is the cardiac response (mainly bradycardia) Trigeminocardiac Reflex associated with stimulation of the ophthalmic division of the trigeminal nerve during ocular surgeries.[7,8] Then, The TCR is defined as the sudden onset of parasympathetic Schaller, for the first time, demonstrated that a similar dysrhythmia, sympathetic hypotension, apnea, or Neurology India | Jul-Aug 2009 | Vol 57 | Issue 4 375 Arasho, et al.: Trigeminocardiac reflex gastric hyper-motility during stimulation of any of the with the same definition used as in his prior study, i.e., sensory branches of the trigeminal nerve.[1] The proposed heart rate less than 60 beats per minute and MABP 20% mechanism for the development of the TCR is that the lower than the baseline.[20] TCR was also reported during sensory nerve endings of the trigeminal nerve send transsphenoidal surgery for pituitary adenoma.[9,19,21] neuronal signals via the Gasserian ganglion to the sensory Among 117 patients who underwent transsphenoidal nucleus of the trigeminal nerve, forming the afferent surgery for pituitary adenoma, 10% developed a TCR pathway of the reflex arc.[1,2] This afferent pathway during the surgical procedure.[19] Peripheral stimulation continues along the short internuncial nerve fibres in the of the naso-pharynx may also lead to TCR.[9] reticular formation to connect with the efferent pathway in the motor nucleus of the vagus nerve. Several lines Risk Factors for Occurrence of the of experimental evidence demonstrate that trigeminally Trigeminocardiac Reflex induced cardiovascular reflexes could be mediated initially in the trigeminal nucleus caudalis and subsequently in the As there is a lack of detailed knowledge of the physiology parabrachial nucleus, the rostral ventrolateral medulla of the TCR and since we cannot treat in whole the TCR, oblongata, the dorsal medullary reticular field, and the the risk factors gain increased importance. The risk [3,10,11] paratrigeminal nucleus in animal models. factors already known to increase the incidence of TCR include: (i) hypercapnia; (ii) hypoxemia; (iii) light general The TCR occurs during both, the peripheral and the anesthesia; (iv) age (more pronounced in children); (v) the central manipulations of the trigeminal nerve. The OCR, nature of the provoking stimulus (stimulus strength and which is a subform of the TCR, has long been reported duration); and (vi) drugs. Drugs known to increase the [7,8,12] in patients with ocular surgeries and manipulations. TCR include: (i) potent narcotic agents (sufentanil and In 1999, Schaller et al., for the first time, reported the alfentanil);[22,23] (ii) beta-blockers; and (iii) calcium channel occurrence of the TCR in skull base and neurological blockers.[24] Narcotics may augment vagal tone through [1] surgeries. The underlying responsible mechanism is their inhibitory action on the sympathetic nervous not yet fully understood, but is believed to be the same system.[1,25-27] Beta-blockers reduce the sympathetic as the OCR reported earlier on, i.e., activation of the response of the heart and by so doing, augment the [2] central or intracranial portions of the trigeminal nerve. vagal cardiac response resulting in bradycardia. Calcium channel blockers result in peripheral arterial smooth Epidemiology of the Trigeminocardiac Reflex muscle relaxation and vasodilatation causing reduction in blood pressure. In patients undergoing trigeminal It has been demonstrated that the TCR may occur manipulations, this worsens the vagal effect that occurs with manipulation of all the branches of the trigeminal in some patients. nerve anywhere along its (intracranial or extracranial) course.[7,8,12- 16] The OCR, which is a subvariant of the TCR, Case Report and studied far earlier, was said to occur in up to 67% of the patients operated for strabismus,[17] but a lot of authors A 60-year-old male patient with a diagnosis of right-sided only studied the heart rate and a reduction in heart rate vestibular schwannoma underwent tumor resection by 10% or more was taken as a positive OCR, so that the via a retrosigmoid (suboccipital approach) approach. real incidence may be substantially smaller. According His medical history was significant for long standing to Schaller’s experience, the TCR occurs in 10-18% of the hypertension for which he is taking irbesartan (an patients.[1,18-20] In a retrospective review of 125 patients angiotensin receptor blocker) and a 14-pack-year history operated for tumors of the cerebello-pontine angle, of smoking. Otherwise, he has no history of diabetes, Schaller et al. noticed the occurrence of the TCR in 11% of cardiac problems, and was not on beta blockers or calcium the operated patients.[4] Three of the patients in this series channel blockers. His baseline MABP was 73.2 mm Hg developed asystole which lasted from 30- 70 seconds.[1] and heart rate was 65 beats per minute. Two hours after In contrast to the studies on OCR, Schaller take into skin incision, his MABP dropped to 43.3 mm Hg (40.8% consideration the heart rate and blood pressure into drop from the baseline) and concomitantly, his heart account and defined TCR as heart rate less than 60 beats rate dropped to 40 beats per minute (38% drop from per minute and mean arterial blood pressure (MABP) 20% the baseline). Then, the procedure was discontinued; lower than the baseline.[1] he was given epinephrine and crystalloid fluids. After five minutes, his MABP and heart rate stabilized and the In another study, Schaller also showed the occurrence surgical procedure was carried out successfully to the of TCR during microvascular decompression of the end without any further episodes of TCR. His oxygen trigeminal nerve for trigeminal neuralgia.[20] In this saturation was 100% and no hypercarbia occurred. The review on 28 patients, the incidence of TCR was 18% postoperative course was uneventful. 376 Neurology India | Jul-Aug 2009 | Vol 57 | Issue 4 Arasho, et al.: Trigeminocardiac reflex Clinical significance of the trigeminocardiac reflex occurrence of postoperative ipsilateral tinnitus: The and why it should be treated overall incidence of postoperative ipsilateral tinnitus Most authors recognized that the
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